Improving the Quality of
Health Care for Mental
and Substance-Use
Conditions
Recommendations
&
Work Group Assignments
Work Group Assignments
What are the opportunities and challenges that
are addressed by each workgroup?
2. What can and should be done in each area?
(the great ideas)
3. What can you or your organization pledge as
an action plan to help implement the new IOM
Report? And how can we measure progress of
success?
Improving the Quality of Health Care for Mental
and Substance-Use Conditions
1.
Discussion Guidelines
 Each
work group serves as an expert
panel – No formal group presentation
 Open discussion for each area
 Pledges from the group and others

Pledge follow up process
• Recorded and tabulated
• Carter Center follow up
• Reports on progress
Improving the Quality of Health Care for Mental
and Substance-Use Conditions (27 Recommendations)
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2 Overarching Recommendations
3.1-2 Supporting Patient Decision- Making Abilities
and Preferences
4.1-5. Structuring the Evidence Base and Quality
Improvement Infrastructure
5.1-4. Coordinating Care For Better Mental,
Substance Use, and General Health
6.1-4. Fully Integrating Mental and Substance Use
Health Care Into The National Health Information
Infrastructure
7.1-4. Increasing Workforce Capacity For Quality
Improvement
8.1-4. Using Marketplace Incentives to Leverage
Needed Change
9.1-2. Coordinating and Broadening Research
Improving the Quality of Health Care for
Mental and Substance-Use Conditions
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Recommendations - Overarching
Health care for general, mental, and substanceuse problems and illnesses must be delivered
with an understanding of the inherent
interactions between the mind/brain and the rest
of the body.
 The aims, rules, and strategies for redesign set
forth in Crossing the Quality Chasm should be
applied throughout M/SU health care on a dayto-day operational basis but tailored to reflect
the characteristics that distinguish care for these
problems and illnesses from general health care.
Supporting Patient Decision
Making Abilities and Preferences
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3.1 To promote patient-centered care, all parties
involved in health care for mental or substanceuse conditions should support the decisionmaking abilities and preferences for treatment
and recovery of persons with M/SU problems
and illnesses.
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Clinicians and organizations providing M/SU
treatment services should:
Organizations providing M/SU treatment should:
Health plans and direct payers of M/SU treatment
services should:
Supporting Patient Decision
Making Abilities and Preferences
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3.1 Clinicians and organizations providing M/SU treatment
services should
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Incorporate informed, patient-centered decision-making throughout
their practices, including active patient participation in the design
and revision of patient treatment and recovery plans, the use of
psychiatric advance directives, and (for children) informed family
decision-making. To ensure informed decision-making, information
on the availability and effectiveness of M/SU treatment options
should be provided.
Adopt recovery-oriented and illness self-management practices that
support patient preferences for treatment (including medications),
peer support, and other elements of the wellness recovery plan.
Maintain effective, formal linkages with community resources to
support patient illness self-management and recovery.
Supporting Patient Decision
Making Abilities and Preferences
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3.1 Organizations providing M/SU treatment should
 Have in place policies that implement informed,
patient-centered participation and decision-making in
treatment, illness self-management, and recovery
plans.
 Involve patients and their families in the design,
administration, and delivery of treatment and recovery
services.
 Accrediting bodies should adopt accreditation
standards that require the implementation of those
practices.
Supporting Patient Decision
Making Abilities and Preferences
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3.1 Health plans and direct payers of M/SU treatment services
should
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For persons with chronic mental illnesses or
substance-use dependence, pay for peer support and
illness self-management programs that meet
evidence-based standards.
Provide consumers with comparative information on
the quality of care provided by practitioners and
organizations and use this information themselves
when making their purchasing decisions.
Remove barriers to and restrictions on effective and
appropriate treatment that may be created by copayments, service exclusions, benefit limits, and other
coverage policies.
Supporting Patient Decision
Making Abilities and Preferences
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3.2 Coercion should be avoided whenever possible.
When coercion is legally authorized, patientcentered care is still applicable and should be
undertaken by
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Making the policies and practices used for
determining dangerousness and decision-making
capacity transparent to patients and their caregivers.
Obtaining the best available comparative information
on safety, effectiveness, and availability of care and
providers and using it to guide treatment decisions.
Maximizing patient decision-making and involvement
in the selection of treatments and providers
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.1 To build and disseminate the evidence base
better, the Department of Health and Human
Services (DHHS) should strengthen, coordinate,
and consolidate the synthesis and dissemination of
evidence on effective M/SU treatments and
services by - SAMHSA; NIMH; NIDA; NIAA;
National Institute of Child Health and Human
Development; AHRQ; Department of Justice; VA;
Department of Defense; Department of Education;
Centers for Disease Control and Prevention;
Centers for Medicare and Medicaid Services;
Administration for Children, Youth, and Families;
states; professional associations; and other privatesector entities.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.1 (Continued) To implement this recommendation, DHHS
should charge or create one or more entities to
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Describe and categorize available M/SU preventive,
diagnostic, and therapeutic interventions (including
screening, diagnostic, and symptom-monitoring tools)
and develop individual procedure codes and
definitions for these interventions and tools for their
use in administrative datasets approved under HIPAA.
Assemble the scientific evidence on the efficacy and
effectiveness of these interventions, including their
use in varied age and ethnic groups; use a wellestablished approach to rate the strength of this
evidence and categorize the interventions
accordingly; and recommend or endorse guidelines
for the use of the evidence-based interventions for
specific M/SU problems and illnesses.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.1 (Continued) To implement this recommendation, DHHS
should charge or create one or more entities to
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Substantially expand efforts to attain widespread
adoption of evidence-based practices through the use
of evidence-based approaches to knowledge
dissemination and uptake. Dissemination strategies
should always include entities that are commonly
viewed as knowledge experts by general health care
providers and makers of public policy, including the
Centers for Disease Control and Prevention, the
Agency for Healthcare Research and Quality, the
Centers for Medicare and Medicaid Services, the
Office of Minority Health, and professional
associations and health care organizations.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.2 Clinicians and organizations providing M/SU
services should
 Increase their use of valid and reliable patient
questionnaires or other patient-assessment
instruments that are feasible for routine use to
assess the progress and outcomes of treatment
systematically and reliably.
 Use measures of the processes and outcomes of
care to continuously improve the quality of the
care they provide.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.3 To measure quality better, DHHS in
partnership with the private sector should charge
and financially support an entity similar to the
National Quality Forum to convene government
regulators, accrediting organizations, consumer
representatives, providers, and purchasers
exercising leadership in quality-based
purchasing for the purpose of reaching
consensus on and implementing a common,
continuously improving set of M/SU health care
quality measures for providers, organizations,
and systems of care. Participants in this
consortium should commit to:
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.3 (Continued) Participants in this consortium should commit to:
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Requiring the reporting and submission of the quality
measures to a performance measure repository or
repositories.
Requiring validation of the measures for accuracy and
adherence to specifications.
Ensuring the analysis and display of measurement
results in formats understandable by multiple
audiences, including consumers, those reporting the
measures, purchasers, and quality oversight
organizations.
Establishing models for the use of the measures for
benchmarking and quality improvement purposes at
sites of care delivery.
Performing continuing review of the measures’
effectiveness in improving care.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.4 To increase quality improvement capacity,
DHHS in collaboration with other government
agencies, states, philanthropic organizations,
and professional associations should create or
charge one or more entities as national or
regional resources to test, disseminate
knowledge about, and provide technical
assistance and leadership on quality
improvement practices for M/SU health care in
public-sector and private-sector settings.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.5 Public and private sponsors of research on M/SU and
general health care should include the following in their
research funding priorities:
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Development of reliable screening, diagnostic and
monitoring instruments that can validly assess
response to treatment and that are practicable for
routine use. These instruments should include a set of
M/SU “vital signs”: a brief set of indicators—
measurable at the patient level and suitable for
screening and early identification of problems and
illnesses and for repeated administration during and
following treatment—to monitor symptoms and
functional status. The indicators should be
accompanied by a specified standardized approach
for routine collection and reporting as part of regular
health care. Instruments should be age-appropriate
and culturally appropriate.
Structuring the Evidence Base and
Quality Improvement Infrastructure
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4.5 (Continued) Public and private sponsors of research on
M/SU and general health care should include the following in
their research funding priorities:
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Refinement and improvement of these instruments,
procedures for categorizing M/SU interventions, and
methods for providing public information on the
effectiveness of those interventions.
Development of strategies to reduce the
administrative burden of quality monitoring systems
and to increase their effectiveness in improving
quality.
Coordinating Care for Better Mental,
Substance Use, and General Care
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5.1 To make collaboration and coordination of patients’ M/SU health
care services the norm, providers of the services should establish
clinically effective linkages within their own organizations and
between providers of mental health and substance-use treatment.
The necessary communications and interactions should take place
with the patient’s knowledge and consent and be fostered by
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Routine sharing of information on patients’ problems
and pharmacologic and non-pharmacologic
treatments among and between providers of M/SU
treatment.
Valid, age-appropriate screening of patients for comorbid mental, substance-use, and general medical
problems in these clinical settings and reliable
monitoring of their progress.
Coordinating Care for Better Mental,
Substance Use, and General Care
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5.2 To facilitate the delivery of coordinated care
by primary care, mental health, and substanceuse treatment providers, government agencies,
purchasers, health plans, and accreditation
organizations should implement policies and
incentives to continually increase collaboration
among these providers to achieve evidencebased screening and care of their patients with
general, mental, and/or substance-use health
conditions. The following specific measures
should be undertaken to carry out this
recommendation:
Coordinating Care for Better Mental,
Substance Use, and General Care
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5.2 (Continued) The following specific measures should be
undertaken to carry out this recommendation:
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Primary care providers and specialty M/SU health care
providers should transition along a continuum of
evidence-based coordination models from (1) formal
agreements among mental, substance-use, and
primary health care providers to (2) case management
of mental, substance-use, and primary health care to
(3) collocation of mental, substance-use, and primary
health services and then to (4) delivery of mental,
substance-use, and primary health care through
clinically integrated practices of primary and M/SU care
providers. Organizations should adopt models to which
they can most easily transition from their current
structure, that best meet the needs of their patient
populations, and that ensure accountability.
Coordinating Care for Better Mental,
Substance Use, and General Care
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5.2 (Continued) The following specific measures should be
undertaken to carry out this recommendation:
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DHHS should fund demonstration programs to offer
incentives for the transition of multiple primary care
and M/SU practices along this continuum of
coordination models.
Purchasers should modify policies and practices that
preclude paying for evidence-based screening,
treatment, and coordination of M/SU care and require
(with patients’ knowledge and consent) all health care
organizations with which they contract to ensure
appropriate sharing of clinical information essential for
coordination of care with other providers treating their
patients.
Coordinating Care for Better Mental,
Substance Use, and General Care
 5.2 (Continued) The following specific measures should be
undertaken to carry out this recommendation:
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Organizations that accredit mental, substance-use, or
primary health care organizations should use
accrediting practices that assess, for all providers, the
use of evidence-based approaches to coordinating
mental, substance-use, and primary health care.
Federal and state governments should revise laws,
regulations, and administrative practices that create
inappropriate barriers to the communication of
information between providers of health care for
mental and substance-use conditions and between
those providers and providers of general care.
Coordinating Care for Better Mental,
Substance Use, and General Care
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5.3 To ensure the health of persons for whom they are
responsible, M/SU providers should
Coordinate their services with those of other humanservices and education agencies, such as schools,
housing and vocational rehabilitation agencies, and
providers of services for older adults.
 Establish referral arrangements for needed services.
Providers of services to high-risk populations—such as
child welfare agencies, criminal and juvenile justice
agencies, and long-term care facilities for older adults—
should use valid, age-appropriate and culturally
appropriate techniques to screen all entrants into their
systems to detect M/SU problems and illnesses.
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Coordinating Care for Better Mental,
Substance Use, and General Care
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5.4 To provide leadership in coordination, DHHS should
create a high-level, continuing entity reporting directly to
the secretary to improve collaboration and coordination
across its mental, substance-use, and general health
care agencies, including the Substance Abuse and
Mental Health Services Administration, the Agency for
Healthcare Research and Quality, the Centers for
Disease Control and Prevention, and the Administration
for Children, Youth, and Families. DHHS also should
implement performance measures to monitor its
progress toward achieving internal interagency
collaboration and publicly report its performance on
these measures annually. State governments should
create analogous linkages across state agencies.
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.1 To realize the benefits of the emerging National
Health Information Infrastructure (NHII) for consumers of
M/SU health care services, the secretaries of DHHS and
the Department of Veterans Affairs should charge the
Office of the National Coordinator of Health Information
Technology and the Substance Abuse and Mental Health
Services Administration to jointly develop and implement
a plan for ensuring that the various components of the
emerging NHII—including data and privacy standards,
electronic health records, and community and regional
health networks—address M/SU health care as fully as
general health care. As part of this strategy,
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.1 (Continued) As part of this strategy,
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DHHS should create and support a continuing
mechanism to engage M/SU health care stakeholders in
the public and private sectors in developing consensusbased recommendations for the data elements,
standards, and processes needed to address unique
aspects of information management related to M/SU
health care. The recommendations should be provided
to the appropriate standard-setting entities and
initiatives working with the Office of the National
Coordinator of Health Information Technology.
Federal grants and contracts for the development of
components of the NHII should require and use as a
criterion for making awards the involvement and
inclusion of M/SU health care.
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.1 (Continued) As part of this strategy,
 The Substance Abuse and Mental Health Services
Administration should increase its work with public
and private stakeholders to support the building of
information infrastructure components that address
M/SU health care and coordinate these information
initiatives with the NHII.
 Policies and information technology infrastructure
should be used to create linkages (consistent with all
privacy requirements) among patient records and
other data sources pertaining to M/SU services
received from health care providers and from
education, social, criminal justice, and other agencies.
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.2 Public-sector and private-sector persons and
organizational leaders in M/SU health care
should become involved in, and provide for staff
involvement in, major national committees and
initiatives involved in setting health care data
and information technology standards to ensure
that the unique needs of M/SU health care are
designed into these initiatives at their earliest
stages.
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.3 National associations of purchasers—such as the
National Association of State Mental Health Program
Directors, the National Association of State Alcohol and
Drug Abuse Directors, the National Association of State
Medicaid Directors, the National Association of County
Behavioral Health Directors, the American Managed
Behavioral Healthcare Association, and the national Blue
Cross and Blue Shield Association—should decrease the
burden of variable reporting and billing requirements by
standardizing the requirements at the national, state, and
local levels.
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.4 Federal and state governments, public-sector and private-sector
purchasers of M/SU health care, and private foundations should
encourage the widespread adoption of electronic health records,
computer-based clinical decision-support systems, computerized
provider order entry, and other forms of information technology for
M/SU care by
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Offering financial incentives to individual M/SU
clinicians and organizations for investments in
information technology needed to participate fully in
the emerging NHII.
Providing capital and other incentives for the
development of virtual networks to give individual and
small-group providers standard access to software,
clinical and population data and health records, and
billing and clinical decision-support systems.
Fully Integrating Mental and Substance Use Health
Care Into the National Health Information
Infrastructure
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6.4 (Continued) encourage the widespread adoption of
electronic health records, computer-based clinical decisionsupport systems, computerized provider order entry, and other
forms of information technology for M/SU care by
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Providing financial support for continuing technical
assistance, training, and information technology
maintenance.
Including in purchasing decisions an assessment of
the use of information technology by clinicians and
health care organizations for clinical decision support,
electronic health records, and other quality
improvement applications.
Increasing Workforce Capacity for
Quality Improvement
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7.1 To ensure sustained attention to the development of a stronger
M/SU health care workforce, Congress should authorize and
appropriate funds to create and maintain a Council on the Mental
and Substance-Use Health Care Workforce as a public–private
partnership. Recognizing that the quality of M/SU services is
dependent upon a highly competent professional workforce, the
council should develop and implement a comprehensive plan for
strengthening the quality and capacity of the workforce to improve
the quality of M/SU services substantially by
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Identifying the specific clinical competencies that all
M/SU professionals must possess to be licensed or
certified and the competencies that must be
maintained over time.
Increasing Workforce Capacity for
Quality Improvement
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7.1 (Continued) to improve the quality of M/SU services
substantially by
 Developing national standards for the credentialing and
licensure of M/SU providers to eliminate differences in
the standards now used by the states. Such standards
should be based on core competencies and should be
included in curricula and education programs across all
the M/SU disciplines.
 Proposing programs to be funded by government and
the private sector to address and resolve such longstanding M/SU workforce issues as diversity, cultural
relevance, faculty development, and continuing
shortages of the well-trained clinicians and consumer
providers needed to work with children and the elderly
and of programs for training competent clinician
administrators.
Increasing Workforce Capacity for
Quality Improvement
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7.1 (Continued) to improve the quality of M/SU
services substantially by
 Providing a continuing assessment of M/SU
workforce trends, issues, and financing policies.
 Measuring the extent to which the plan’s objectives
have been met and reporting annually to the nation
on the status of the M/SU workforce.
 Soliciting technical assistance from public–private
partnerships to facilitate the work of the council and
the efforts of educational and accreditation bodies to
Increasing Workforce Capacity for
Quality Improvement
 7.2
Licensing boards, accrediting bodies,
and purchasers should incorporate the
competencies and national standards
established by the Council on the Mental
and Substance-Use Health Care
Workforce in discharging their regulatory
and contracting responsibilities.
Increasing Workforce Capacity for
Quality Improvement
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7.3 The federal government should support the
development of M/SU faculty leaders in health
professions schools, such as schools of nursing
and medicine, and schools and programs that
educate M/SU professionals, such as
psychologists and social workers. The aim
should be to narrow the gaps among what is
known through research, what is taught, and
what is done by those who provide M/SU
services.
Increasing Workforce Capacity for
Quality Improvement
 7.4
To facilitate the development and
implementation of core competencies
across all M/SU disciplines, institutions of
higher education should place much
greater emphasis on interdisciplinary
didactic and experiential learning and
should bring together faculty and trainees
from their various education programs.
Using Marketplace Incentives to
Leverage Needed Change
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8.1 Health care purchasers that offer enrollees a choice
of health plans should evaluate and select one or more
available tools for use in reducing selection-related
incentives to limit the coverage and quality of M/SU
health care. Risk adjustment, payer “carveouts”, risksharing or mixed-payment contracts, and benefit
standardization across the health plans offered can
partially address selection-related incentives. Congress
and state legislatures should improve coverage by
enacting a form of benefit standardization known as
parity for coverage of M/SU treatment.
Using Marketplace Incentives to
Leverage Needed Change
 8.2
State government procurement
processes should be reoriented to give the
most weight to the quality of care to be
provided by vendors.
Using Marketplace Incentives to
Leverage Needed Change
 8.3
Government and private purchasers
should use M/SU health care quality
measures (including measures of the
coordination of health care for mental,
substance-use, and general health
conditions) in procurement and
accountability processes.
Using Marketplace Incentives to
Leverage Needed Change
 8.4
State and local governments should
reduce the emphasis on the grant-based
systems of financing that currently
dominate public M/SU treatment systems
and should increase the use of funding
mechanisms that link some funds to
measures of quality.
Coordinating and Broadening
Research
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9.1 The secretary of the Department of HHS should provide
leadership, strategic development support, and additional
funding for research and demonstrations aimed at improving
the quality of M/SU health care. This initiative should
coordinate the existing quality improvement research efforts
of the NIMH, NIDA, National Institute on Alcohol Abuse and
Alcoholism, Department of VA, SAMHSA, Agency for
Healthcare Research and Quality, and Centers for Medicare
and Medicaid Services, and it should develop and fund
cross-agency efforts in necessary new research.
 To that end, the initiative should address the full range of
research needed to reduce gaps in knowledge at the
clinical, services, systems, and policy levels and should
establish links to and encourage expanded efforts by
foundations, states, and other nonfederal organizations.
Coordinating and Broadening
Research

9.2 Federal and state agencies and private foundations should
create health services research strategies and innovative
approaches that address treatment effectiveness and quality
improvement in usual settings of care delivery. To that end, they
should
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develop new research and demonstration funding
models that encourage local innovation, that include
research designs in addition to randomized controlled
trials, that are committed to partnerships between
researchers and stakeholders, and that
create a “critical mass” of interdisciplinary research
partnerships involving usual settings of care.
Stakeholders should include consumers/ patients,
parents or guardians of children, clinicians and clinical
teams, organization managers, purchasers, and
policy makers.